Heritage Manor Health & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to implement a comprehensive person-centered care plan which met the needs of 1 (#1) of 4 sampled residents reviewed for falls. The facility failed to ensure Resident #1 received one on one monitoring at all times as ordered.Findings: Review of Resident #1's medical record revealed an admission date of [DATE] under hospice services with diagnoses including chronic obstructive pulmonary disease and major depressive disorder. Further review of Resident #1's medical revealed Resident #1 expired on [DATE].Review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 14, indicating intact cognition. Further review of Resident #1's admission MDS assessment revealed Resident #1 was dependent on staff for transfers.Review of Resident #1's physician orders revealed an order dated [DATE] which read Resident #1 is on 1:1 monitoring at all times for safety; Resident #1 to sit in wheelchair/Geri-chair near nurses station for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop a Comprehensive Person Centered Care Plan, which met the needs of 1 (#1) of 3 sampled residents. The facility failed to ensure physician recommendations were followed and interventions were in place for a subacute-chronic olecranon fracture. Findings:Review of the facility's Comprehensive Care Plans undated policy revealed in part:Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Policy Explanation and Compliance Guidelines:3. The comprehensive care plan will describe, at a minimum, the following:a. the services that are to be furnished to attain or maintain the resident's highest practicable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure 2 (#3, #5) out of 5 sampled residents were free from abuse resulting in resident to resident interactions. The facility failed to develop and implement ongoing monitoring to ensure resident safety.Findings:Review of Resident #3's medical records revealed an admit date of 12/05/2022 with the following diagnoses, in part: personal history of traumatic brain injury.Review of Resident #3's facility initiated investigation in part, revealed event occurred on12/03/2025 and type of injury was sexual assault. Further review revealed during the investigation, Resident #5 reported to Social Services Director (SSD) two weeks prior the accused tried to touch her but didn't report it because he stopped. The iknvestigation failed to include plans to conduct ongoing monitoring following the incident.Review of Resident #3's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to provide needed care and services, in accordance with the resident's goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. The facility failed to ensure 1 (#4) out of 5 sampled residents received medication ordered upon re-ademission to the facility.Findings:Review of Resident #4's medical record revealed an admit date of 04/04/2022 with the following diagnoses, in part: major depressive disorder recurrent and unspecified and anxiety disorder.Review of Resident #4's hospital psychiatric evaluation revealed an admit date of 10/23/2025, date of evaluation 10/24/2025 and discharge date of 10/30/2025. Further review, in part revealed: .admitted for unstable mood and cannabis use disorder. Discharge goal: He needs to have a stable mood, be free of any agitation, maintain sobriety, and improve coping skills. Discharge medication summary included, in part: Divalproex Sodium DRT (delayed release time) 250 mg (milligarm) by mouth daily 9:00 a.m. and 9:00 p.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. The facility failed to document 1 (#1) out of 2 residents discharge from the facility.Findings:Review of Resident #1's medical records revealed an admit date of 10/09/2025 and a discharge date of 10/13/2025 with the following diagnoses, in part: chronic obstructive pulmonary disease unspecified, essential (primary) hypertension, other bipolar disorder, chronic kidney disease stage 3 unspecified, unspecified atrial fibillation, displaced subtrochanter fracture of right femur, displace transverse fracture of shaft of left ulna, displace fractureof medial condyle of left tibia, non-displced fracure of body of scapula left shoulder and contusion of lung unilateral subsequent encounter.Review of the facility census failed to reveal Resident #1 was in the facility.Review of Resident #1's medical record failed to reveal date, time, and events of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to develop a baseline care plan for 1 (#1) out of 5 sampled residents reviewed.Findings:Review of Resident #1's medical records revealed an admit date of 10/09/2025 with the following diagnoses, in part: chronic obstructive pulmonary disease unspecified, essential (primary) hypertension, other bipolar disorder, chronic kidney disease stage 3 unspecified, unspecified atrial fibillation, displaced subtrochanter fracture of right femur, displace transverse fracture of shaft of left ulna, displace fractureof medial condyle of left tibia, non-displced fracure of body of scapula left shoulder and contusion of lung unilateral subsequent encounter. Review of Resident #1's medical record failed to reveal a baseline care plan. During an interview on 12/16/2025 at 10:25 a.m. S4 MDS (Minimum Data Set) nurse confirmed Resident #4 did not have a baseline care plan developed and should have.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure 5 (#1, #6, #7, #8, and #49) of 5 (#1, #6, #7, #8, and #49) residents reviewed for unnecessary medications were informed of the risks, benefits, and side effects of psychotropic medication, and allowed to choose the treatment option they preferred prior to the start of the medication. Findings:Resident #1 Review of Resident #1's record revealed an initial admission date of 01/17/2025 with a re-entry admission date of 02/17/2025 with the following diagnoses but not limited to generalized muscle weakness, lack of coordination, difficulty in walking, cognitive communication deficit, severe vascular dementia with agitation, uncomplicated stimulant abuse, and metabolic encephalopathy. Review of Resident #1's Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 14 indicating intact cognition. Further review of Resident #1's MDS revealed Resident #1 received antipsychotic and antianxiety.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations, and interviews, the facility failed to ensure residents received services with reasonable accommodation of resident needs. The facility failed to ensure:1. Resident #54's call light functioned properly and Resident #54's calls for assistance were answered in a timely manner.2. The emergency call light in the hall bathroom between room A and room B had a pull cord in place. Findings: 1. Review of Resident #54’s medical record revealed an admit date of 07/31/2025 with a diagnoses of but not limited to spondylosis without myelopathy or radiculopathy lumbosacral region, scoliosis, unspecified and type 2 diabetes. Review of Resident #54’s Quarterly MDS (Minimum Data Set) dated 07/09/2025 revealed Resident #54 was assessed to have a BIMS (Brief Interview Mental Status) score of 13 indicating intact cognition. Review of Resident #54’s comprehensive plan of care revealed a problem of: the resident has an ADL (activities of daily living) self-performance deficit with interventions of total dependence with one person assistance for toilet use, total…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews, the facility failed to ensure residents who received psychotropic drugs were free from unnecessary drugs for 1 (#7) of 5 (#1, #6, #7, #8, and #49) residents reviewed for unnecessary medication. The facility failed to ensure:1. Pharmacy GDR (gradual dose reduction) requests were conducted and communicated to the physician for consideration.2. Psych NP (Nurse Practitioner) recommendation was communicated to the physician for consideration. Findings: Review of Resident #7's medical record revealed an initial admission date of 12/09/2014 with diagnoses that included, in part, insomnia unspecified; major depressive disorder single episode unspecified; major depressive disorder recurrent unspecified; bipolar disorder current episode, depressed, severe with psychotic features; and anxiety disorder unspecified. Review of Resident #7's 06/18/2025 Quarterly MDS (minimum data set) assessment revealed Resident #7 had a BIMS (Brief Interview Mental Status) score of 11, which indicated moderate cognitive impairment. Review of Resident #7's physician orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to provide to the resident and/or resident representative written notice which specified the reason for transfer, effective date, location, statement of the resident's appeal rights, and duration of the bed hold policy and failed to notify the State's Long-Term Care Ombudsman of discharges in writing for 4 (#2, #56, #58, #62) of 4 (#2, #56, #58, #62) sampled residents reviewed for discharge and transfer requirements.Findings:Review of the facility's Bed-Hold Policy (undated) revealed in part: Purpose: Ensure that residents are made aware of a facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility.Procedure1. The facility has a bed-hold policy and readmission policy that outlines the terms and conditions for holding a bed if the resident is transferred out of the facility for any reason. 2. The facility will notify the resident at the time of admission and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure resident assessments accurately reflected the residents' status for 2 (#8, #34) of 22 sampled residents reviewed for accurate assessments. The facility failed to accurately assess Resident #8 for insulin administration via injection, and failed to complete Resident #34's discharge assessment.Findings: Resident #8 Review of Resident #8's record revealed an initial admission date of [DATE], a readmission date of [DATE], and diagnoses including type 2 diabetes mellitus with hyperglycemia. Review of Resident #8's current physician orders revealed orders including: -[DATE] Lantus (insulin) Subcutaneous Solution 100 unit/ml (units/milliliter), Inject 32 units subcutaneously two times a day -[DATE] -[DATE] Novolog (insulin) penfill subcutaneous solution cartridge 100 unit/ml, Inject as per sliding scale Review of Resident #8's quarterly MDS (Minimum Data Set) dated [DATE] revealed Resident #8 was assessed to not have received injections of any type…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews the facility failed to ensure a resident's plan of care was implemented for 1 (#49) of 5 (#1, #6,#7, #8, #49) residents reviewed for unnecessary medications. The facility failed to ensure resident #49's laboratory tests were done as ordered. Findings: Review of Resident #49's medical record revealed an initial admit date of 12/12/2023 and a re-admission date of 06/02/2025 with diagnoses of but not limited to morbid obesity, type 2 diabetes, Olgilvie syndrome, megacolon, hypomagnesemia, essential hypertension and functional quadriplegia. Review of Resident #49's August 2025 physician's orders revealed orders for: Vitamin D level ordered 12/24/2024Lipid panel annually in May ordered 01/27/2025 Review of Resident #49's medical record failed to reveal laboratory results for a Vitamin D level and annual lipid panel. During an interview on 08/05/2025 at 2:45 p.m. S3ADON (Assistant Director of Nurses) confirmed Resident #49's ordered lab work for a Vitamin D level and an annual lipid panel for May 2025 was not done and should have been

Based on observations, record review, and interviews the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 (#54) of 3 (#37, #54, #62) residents reviewed for ADLs (activities of daily living). The facility failed to ensure Resident #54 received nail care and a shave.Findings:Review of Resident #54's medical record revealed an admit date of 07/31/2025 with a diagnoses of but not limited to spondylosis without myelopathy or radiculopathy lumbosacral region, scoliosis, unspecified and type 2 diabetes.Review of Resident #54's Quarterly MDS (Minimum Data Set) dated 07/09/2025 revealed Resident #54 was assessed to have a BIMS (Brief Interview Mental Status) score of 13 indicating intact cognition.Observation on 08/04/2025 at 8:40 a.m. revealed Resident #54 had an unshaved face and fingernails on both hands that protruded past his nail beds. Observation on 08/06/2025 at 9:00 a.m. revealed Resident #54 had an unshaved face and fingernails on both hands that protruded…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to ensure residents received treatment and care and services in accordance with professional standards of practice for 2 (#6, #8) of 5 (#1, #6, #7, #8, and #49) residents reviewed for unnecessary medications. The facility failed to ensure medications were administered, assessments were conducted, and monitoring was performed as ordered.Findings:Resident #6 Review of Resident #6's record revealed an initial admit date of 05/02/2025, readmission on [DATE], and diagnoses including: methicillin susceptible staphylococcus aureus infection, unspecified site, proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere, bacteremia, osteomyelitis of vertebra, lumbar region, metabolic encephalopathy, essential (primary) hypertension, sepsis, unspecified organism, age-related physical debility, paroxysmal atrial fibrillation, Wernicke's encephalopathy, unspecified psychosis not due to a substance or known physiological condition, chronic metabolic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 3 (#8, #26, and #59) of 4 (#8, #26, #44, and #59) residents reviewed for respiratory care. The facility failed to ensure oxygen supplies were dated, humidification bottles were not empty, and oxygen concentrator filters were clean. Findings:Review of the facility's undated Oxygen Administration Policy revealed in part:PROCEDURE8. Label humidifier with date and time opened. Change humidifier and tubing per facility policy.10. At regular intervals, check and clean oxygen equipment, masks, tubing and cannula. 11. At regular intervals, check liter flow contents of oxygen cylinder, fluid level in humidifierDOCUMENTATION GUIDELINESHumidifier should be labeled with the date and time changedResident #8Review of Resident #8's record revealed an initial admission date of 03/14/2024, a readmission date of 08/14/2024, and diagnoses including chronic obstructive pulmonary disease.Review of Resident #8's current physician orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to (1) document least restrictive approaches before installation of bed rail/side rail, (2) obtain a written order from the physician for bed rails/side rails use, (3) obtain an informed consent from resident from resident or resident representative prior to installation (4) ensure resident care plan included a focus for bed rails/side rails, and (5) ensure maintenance of bed rails/side rails for 1 (#37) out of 1 residents reviewed for accidents. Review of facility's Bed Rail Policy (undated) revealed in part:Purpose: Ensure correct installation, use and maintenance of bed railsProcedure: This facility will attempt to use appropriate alternatives prior to installing a side or bed railIf a bed or side rail is used, this facility must ensure correct installation, use and maintenance of bed rails, including but not limited to the following elements1) Assess the resident for risk of entrapment from bed rails prior to installation.2) Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure there were a sufficient number of personnel to provide care and respond to each resident's basic needs. The facility failed to provide the minimum required staffing hours for 1 of 14 days reviewed. Findings: Review of the Facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form for 07/20/2025 to 08/02/2025 revealed hours provided were less than hours required on Sunday 07/20/2025. The census on 07/20/2025 was 53, hours of care required was 124.55, and the hours of care provided was 120.83 revealing negative 3.72 hours of care provided. During an interview on 08/05/2025 at 4:32 p.m. S1 Administrator confirmed the facility did not meet the required minimum staffing hours on Sunday 07/20/2025 and should have.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure residents' drug regimen was free of unnecessary medications for 2 (#8, #49) of 5 (#1, #6, #7, #8, #49) residents reviewed for unnecessary medications. The facility failed to monitor for behaviors and side effects of psychotropic medication. Findings:Finding: Resident #8 Review of Resident #8's record revealed an initial admission date of 03/14/2024, a readmission date of 08/14/2024, and diagnoses including: restlessness and agitation, paranoid schizophrenia, and major depressive disorder. Review of Resident #8's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 12 indicating moderately impaired cognition. Review of Resident #8's current physician orders revealed orders including:-07/21/2025-Risperdal oral Tablet 3 mg (milligrams) (Risperidone) give 6 mg orally one time a day for paranoid schizophrenia-01/28/2025- Risperdal oral tablet 4 mg (Risperidone) give 1 tablet by mouth at bedtime-01/28/2025-Trazodone Hydrochloride 75 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews and interviews the facility failed to maintain a facility medication error rate of less than 5% by failing to give 3 medications as ordered for 3 (#27, #31, and #36) residents observed during medication administration. A total of 31 opportunities were observed which included 3 medication errors for a medication error rate of 9.68%.Findings: Observation on 08/05/2025 at 8:06 a.m. of medication administration revealed S3 ADON (assistant director of nurses) did not administer Resident #27's Miralax 17 gm (grams) during medication administration. Review of Resident #27's physician's orders revealed an order for Miralax 17gm by mouth once a day for constipation. Observation on 08/05/2025 at 7:48 a.m. during medication administration revealed S3 ADON did not administer Resident #31's Miralax 17gm during medication administration.Review of Resident #31's Physicians orders revealed an order dated 01/28/2025 for Miralax 17gm 1 scoop two times a day for constipation. Observation on 08/05/2025 at 7:11a.m. during medication administration revealed S3ADON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to follow the prescribed diet for 1 (#1) of 1 (#1) residents reviewed for Food/Nutrition. Findings:Review of the facility's Policy: Diet Changes and Reports (undated) revealed in part:Purpose: Ensure communication to the dietary department of any changes in the resident's diet, meal service, eating habits and/or changes in the resident's condition.Procedure:1. When a new resident is admitted , or a diet has been changed, the charge nurse shall be responsible for ensuring that the dietary department receives a written notice of the diet order.Review of Resident #1's medical record revealed an initial admission date of 01/17/2025 with a re-entry admission date of 02/17/2025 with the following medical diagnoses: type 2 diabetes mellitus, hyperlipidemia, and cerebral infarction. Review of Resident #1's August 2025 Physician Orders revealed an order dated 07/23/2025 for a CCD (Consistent Carbohydrate Diet) NAS (No Added Salt) diet, Regular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, observations, and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure:1. Food was stored in accordance with professional standards for food service safety. 2. High Temperature Dishwasher met wash cycle and rinse cycle temperature recommendations. This deficient practice had the potential to affect the 54 residents who received meals on 08/04/2025 as per S12Dietary Manager. Findings:1.Review of undated Policy: Storage of Food in Refrigeration revealed, in part,:Purpose: Ensure food needing refrigeration is properly stored to prevent food-borne illness.Procedure: 4. All containers must be labeled with the contents and date food item was placed in storage.5. Previously cooked foods can be held in refrigeration of 41 degrees F or lower for up to 3 days and then must be discarded.6. Food items that remain sealed from the supplier may be held until the expiration date if unopened. Observation of the facility's refrigerator on 08/04/2025 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure a water management program had been implemented to minimize the risk of Legionella and other opportunistic pathogens. Findings:Review of policies provided by the facility failed to reveal a Water Management Plan was in place and monitoring was being conducted for waterborne illnesses. During an interview on 08/06/2025 at 7:45 a.m. S8Maintenance and S9 Maintenance reported they would conduct water temperature checks only. During an interview on 08/06/2025 at 1:30 p.m. S8 Maintenance and S9 Maintenance reported they had just received a Water Management Program and had picked up a test today to conduct the monitoring. S8 Maintenance and S9 Maintenance further confirmed they had not been aware of this program and had not been conducting any testing on the water, other than water temperatures.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and an interview, the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an advance directive for 1 (#37) of 2 (#2, #37) residents reviewed for advanced directives. Findings:Review of Resident #37's medical record revealed an initial admission date of 07/12/2023 and a re-entry admission on [DATE] with severe morbid obesity, type 2 diabetes mellitus, unspecified lack of coordination, generalized muscle weakness, pain in left shoulder, and unspecified osteoarthritis. Review of Resident #37's admission Packet revealed an Advance Directive Acknowledgment Form was signed by Resident #37. Further review revealed Resident #37's Advance Directive Acknowledgment Form was incomplete, with no options selected. During an interview on 08/06/2025 at 11:30 a.m. S4 Social Services confirmed Resident #37's Advance Directive Acknowledgment Form was not completed and should have been.

Based on observation and interviews the facility failed to maintain all kitchen equipment in safe operating condition as evidenced by the walk-in refrigerator and freezer leaking water and in need of repair. This deficient practice has the potential to affect any of the 51 residents consuming food from the kitchen according to S3 Dietary Manager. Findings: Observation on 06/10/2025 at 8:45 a.m. revealed; 1. water dripping from the water sprinkler into a bucket inside the walk-in refrigerator, 2. water running from the condenser into a bucket and onto the floor in the walk-in freezer, 3. a wooden palate on the floor of the freezer, and 4. ice buildup on the wall and floor of the freezer. During an interview on 06/10/2025 at 9:00 a.m. S2 [NAME] reported the freezer had not been working for approximately one month and water had been leaking from around the condenser, causing water to freeze and build up ice on the floor. S2 [NAME] further reported the walk-in refrigerator had a drip around the sprinkler. During an interview on 06/10/2025 S3 Dietary Manager confirmed water was leaking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to conduct a significant change MDS (Minimum Data Set) for 1 (#1) of 3 (#1, #2, #3) sample residents after changes were noted that had an impact on the resident's health status and required interdisciplinary review and revision of the care plan. Findings: Review of resident #1's electronic medical records revealed a re-entry admission from a behavior hospital on [DATE]. Review of resident #1's Discharge summary dated [DATE] from a local behavioral hospital revealed diagnoses of vascular dementia severe with agitation, bipolar disorder, current episode depressed moderate, medical diagnoses hypertension, atrial fibrillation, acute post procedural hematoma of skin and subcutaneous tissues following other procedure wedge compression fracture of T11-T12 vertebra. Stressors are problems with primary support group, problems related to social environment and housing problems, other psychosocial and environment problems. Prognosis as guarded. Review of resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview the facility failed to ensure standing orders were implemented for 1 (#3) of 3 (#1, #2, #3) residents reviewed. The facility failed to ensure S5 Physician's standing orders for a chest x-ray were completed. Findings: Review of S5 Physician's nursing home standing orders revealed: COVID (corona virus disease) Protocol Standing Orders: Chest X-ray AP (Anteroposterior)/Lateral Review of Resident #3's face sheet revealed an admission date of 05/02/2025 with the following medical diagnoses but not limited to right wrist ganglion metabolic encephalopathy, cellulitis to the right upper limb, repeated falls, other specified disorders of tendon-right shoulder, and mild cognitive impairment uncertain etiology. Review of Resident #3's record failed to reveal results of admit chest x-ray ordered on 05/02/2025. During an interview on 05/28/2025 at 9:30 a.m. S2 ADON (Assistant Director of Nursing) confirmed Resident #3 was admitted to the facility on [DATE] and she called local imaging…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#1) of 3 (#1, #2, #3) sample residents. This is evidenced by the facility failing to continue monitoring and assessment of a resident (#1) after a fall to identify any complications or changes in the resident condition. Findings: Review of facility Falls- Clinical Protocol Policy (undated) revealed in part- Monitoring and Follow-up The staff, with the physician's guidance, will follow-up on any fall with associated injury until the resident is stable and delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. Review of resident #1's hospital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews the facility failed to complete required reporting to the State Survey and Certification Agency in accordance with State law in a timely manner for 1 (#2) of 3 (#1, #2, and #3) sampled residents incidents that required reporting to be submitted. The facility failed to report an allegation of an inappropriate sexual relationship between a staff member and a resident in a timely manner to the State Survey and Certification Agency. Findings: Review of facility's Abuse Prevention Program (undated) revealed in part: Policy statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 7. Investigate and report any allegations of abuse within timeframes as required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing for 1 resident (#3) of 2 residents (#1, #3) reviewed with pressure ulcers. The facility failed to ensure pressure ulcer treatments were performed as ordered and failed to measure and stage pressure ulcers according to professional standards of practice. Findings: Review of Resident #3's medical record revealed and admit date of 02/20/2025 with diagnoses that included in part, stage 4 pressure ulcer sacral region, stage 3 pressure ulcer unspecified hip, personal history healed physical trauma, non-pressure chronic ulcer of right thigh with unspecified severity, pressure ulcer right hip stage 4, pressure ulcer unspecified site stage 2, burn 2nd degree right knee, burn 3rd degree right knee, patient's noncompliance with other medical treatment and regimen for other reason, and contracture of muscle multiple sites. Review of Resident #3's May 2025 Physician Orders revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs. The facility failed to: 1. provide the minimum required staffing hours for 20 of 37 days reviewed and 2. ensure a licensed nurse was designated as a charge nurse for each shift. Findings: Review of the facility completed Nursing Personnel Staffing Pattern Reporting Forms for 03/01/25 to 04/06/2025 revealed insufficient staff below the required minimum hours for the following dates: 03/08/2025: negative 14.93 hours 03/09/2025: negative 23.28 hours 03/11/2025: negative 1.07 hours 03/16/2025: negative 17 hours 03/18/2025: negative 0.29 hours 03/23/2025: negative 16.15 hours 03/24/2025: negative 14.56 hours 03/25/2025: negative 23.05 hours 03/26/2025: negative 7.52 hours 03/27/2025: negative 3.71 hours 03/28/2025: negative 1.83 hours 03/29/2025: negative 6.45 hours 03/30/2025: negative 4.67 hours 03/31/2025: negative 15.74 hours 04/01/2025: negative 12:81 hours…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the provider failed to ensure the facility had 8 consecutive hours per day of Registered Nurse (RN) coverage for 2 of 37 days reviewed for RN hours, and failed to have a DON (Director of Nursing) for 33 consecutive days. This deficient practice had the potential to affect any of the 59 Residents residing in the facility according to the facility's detailed census report. Findings: Review of the facility completed Nursing Personnel Staffing Pattern Reporting Forms for 03/01/2025 to 04/06/2025 revealed no RN coverage 04/02/2025 and 04/03/2025. During an interview on 04/07/2025 at 7:35 a.m. S6 LPN (Licensed Practical Nurse), S7 LPN, and S8 LPN were all at the nursing station and reported the administrator was not in facility and they did not currently have a DON. During an interview on 04/07/2025 at 8:15 a.m. S1 Administrator reported they did not currently have a director of nursing. During an interview on 04/07/25 at 12:20 p.m. S4 HR (Human Resources) confirmed the facility did not have an RN on duty 8 consecutive hours for every day during the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record reviews the facility failed to develop and implement a comprehensive, resident centered plan of care for 2 (#3, #4) out of 5 (#1, #2. #3, #4, #5) sampled residents. Findings: Resident #3 Review of Resident #3's medical record revealed an admit date of 02/14/2025 with diagnoses including but not limited to: Type 2 diabetes mellitus with diabetic chronic kidney disease, morbid obesity, congestive heart failure, generalized edema, dependence on renal dialysis. Review of Resident #3's MDS (Minimum Data Set) assessments dated 03/04/2025 a BIMS (Brief Interview of Mental Status) score of 15 out of 15 indicating the resident was cognitively intact. An observation on 04/07/2025 at 8:55 a.m. revealed Resident #3 had an indwelling urinary catheter draining cloudy urine and a right chest wall dialysis access site. During an interview on 04/07/2025 at 8:55 a.m. Resident #3 reported he was admitted to the facility with the urinary catheter and with the dialysis access site in his right chest wall. Review of Resident #3's comprehensive care plan failed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (#4, #5) of 5 (#1, #2, #3, #4, #5) sampled residents with peg tubes (a feeding tube inserted through the abdomen and into the stomach). The facility failed to ensure accurate skin assessments that reflected a peg tube site for Residents #4 and #5. Findings: Review of the facility's Wound Assessment Policy (no revision date) revealed: Weekly skin review should be done on each resident in PCC [Point Click Care (Electronic Health Record)]. Residents with pressure areas will be reassessed and evaluated by the treatment nurse and assisting RN Registered Nurse) in weekly clinical meeting. Resident #4 Review of Resident #4's medical record revealed an initial admit date of 05/27/2022 with the following diagnoses which included but not limited to: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non-dominant side, acute and chronic respiratory failure, moderate protein-calorie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, observations, and record reviews, the facility failed to ensure a resident admitted with a urinary catheter received necessary treatment and services, consistent with professional standards to promote healing and prevent infections for 1 (#3) of 5 (#1, #2, #3, #4, and #5) sampled residents. Findings: Review of the provider's Catheter Care, Indwelling Catheter policy (undated) revealed in part: Purpose-to prevent urinary tract infection, reduce urethral irritation. -Assessment guidelines may include, but are not limited to: color, consistency, amount of urine -Documentation Guidelines-Documentation includes: date, time, procedure, condition of the perineum and catheter insertion site, any unusual condition or change in condition, color, amount, consistency and odor of urine, notification of the physician of any condition change, intake and output and evaluation of intake and output, signature and title. -Care Plan Documentation Guidelines-record the catheter care as an approach under the appropriate underlying problem on the resident's care plan. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to ensure appropriate care and services had been provided for 1 (#3) of 1 (#3) residents reviewed for Dialysis out of a total of 5 sampled residents. The facility failed to ensure Resident #3 was accurately assessed and monitored for the care of his dialysis access site. Findings: Review of Resident #3's record revealed an admit date of 02/14/2025 and diagnoses including but not limited to: type 2 diabetes mellitus with chronic kidney disease, and dependence on renal dialysis. An observation on 04/07/2025 at 8:55 a.m. revealed Resident #3 had a dressing in place to his right chest wall. During an interview on 04/07/2025 at 8:55 a.m. Resident #3 reported his dialysis access site was in his right chest wall where the dressing was. Review of Resident #3's MDS (Minimum Data Set) assessments dated 03/04/2025 a BIMS (Brief Interview of Mental Status) score of 15 out of 15 indicating the resident was cognitively intact. Further review of section O-Special Treatments, Procedures, and Programs revealed the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure medical records were accurately documented for 2 (#3, #5) of 5 (#1, #2, #3, #4, #5) sampled residents. The facility failed to ensure accurate documentation of weekly skin assessments for Resident #3 and #5, and accurate documentation of dressing changes for Resident #5. Findings: Review of the facility's Wound Assessment Policy (no revision date) revealed: Weekly skin review should be done on each resident in PCC [Point Click Care (Electronic Health Record)]. Residents with pressure areas will be reassessed and evaluated by the treatment nurse and assisting RN (Registered Nurse) in weekly clinical meeting. Resident #3 Review of Resident #3's medical record revealed an admit date of 02/14/2025 and diagnoses including but not limited to: Type 2 Diabetes Mellitus with diabetic chronic kidney disease, type 2 diabetes mellitus with foot ulcers, Fournier gangrene, generalized edema, complete traumatic amputation of right foot. Review of Resident #3's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations, and interviews, the facility failed to maintain an effective infection prevention and control program help prevent the development and transmission of communicable diseases and infections for 2 (#3 and #4) of 5 (#1, #2, #3, #4, and #5) sampled residents as evidenced by failing to ensure: 1. Staff wore appropriate PPE (Personal Protective Equipment) when providing high contact patient care for Resident #3, and #4 who were had Enhanced Barrier Precautions (EBP) in place; 2. Followed appropriate hand hygiene during wound care and incontinence care for Resident #3; and 3. Followed accepted infection control principals during wound care and incontinence care for Resident #3. Findings: Resident #4 Review of Resident #4's medical record revealed an initial admit date of 05/27/2022 with diagnoses including but not limited to: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non-dominant side, acute and chronic respiratory failure, moderate protein-calorie malnutrition and encounter for attention to gastrostomy.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident's advanced directive was honored for 1 (#1) of 5 ( #1, #2, #3, #4, and #5) sampled residents. Findings: The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Review of the provider's Cardiopulmonary Resuscitation (CPR) policy (undated) revealed in part: Procedure-Delegate another individual to check the resident's orders and advance directives for CPR or no CPR order. Review of the provider's Advance Directives policy (revised [DATE]) revealed in part: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Definitions-Do Not Resuscitate (DNR) indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure quarterly statements were provided for 2 (#1, #3) of 5 (#1, #2, #3, #4, #5) residents whose personal funds accounts were reviewed. The facility failed to provide quarterly statements to residents and their responsible parties. Findings: Review of the facility's Personal Funds Policy revealed the following: Purpose: Ensure that each individual record is established for each resident on which only those transactions involving: his/her personal funds are recorded and maintained. 1. The facility must establish and maintain a system that ensures a full and complete and separate accounting, according to generally accepted accounting principles, of each residents personal funds entrusted to the facility on the resident's behalf. 2. The individual financial record must be available to the resident through quarterly statements and upon requests. Resident #1 Review of resident #1's electronic health record revealed resident #1 was admitted to the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews the facility failed to accommodate the needs of 5 (#23, #29, #31, #50, & #54) of 29 sampled residents. The facility failed to ensure: (1) Two (#31, #50) residents call lights were in reach. (2) One (#54) resident call light was functioning. (3) Incontinence briefs were readily available for 2 (#23, #29) residents Findings: (1) Resident #31 Review of Resident #31's medical record revealed Resident #31 was admitted to the facility on [DATE]. Review of Resident #31's 05/15/2024 Quarterly MDS (Minimum Data Set) revealed Resident #31 had a BIMs (Brief Interview Mental Status) score of 06 which indicated severe cognitive impairment and did not have any functional impairment to upper or lower extremities. Observation on 07/14/2024 at 8:15 a.m. revealed Resident #31's call light was wedged between the foot of mattress and foot of bed. During an interview on 07/14/2024 at 8:15 a.m. Resident #31 reported he did not know where his call light was and confirmed it was out…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews the facility failed to act promptly to concerns presented in the resident council meetings. The deficient practice had the potential to affect the total census of 58 residents in the facility according to Long-Term Care Facility Application for Medicare and Medicaid dated 07/14/2024. Findings: Review of facility's Filing Grievances/Complaints policy (undated) revealed in part: Policy statement: Our facility will assist residents or his/her responsible party in filing grievances or complaints when such requests are made. Policy Interpretation and Implementation: 1. Any resident, his or her responsible party may file a grievance or complaint concerning medical care, behavior of other residents, staff members, theft of property, etc. without the fear of threat of reprisal in any form. 3. Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident. 5. Upon receipt of written grievance and/or complaint,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews the facility failed to ensure residents were provided information regarding formulation of advance directive upon their admission for 4 (#8, #17, #23, #50) of 24 initial pool residents. Findings: Review of undated Advance Directives Policy revealed in part: Policy: It is the policy of the Facility to respect the resident's right of self-directed care including the right to issue Advance Directives on health care, to refuse or accept treatment, to make informed decisions, and/or appoint a health care agent to make decision on the behalf of the resident when the resident lacks the capacity to do so. 2. Upon admission the facility will provide each resident medically deemed competent or resident's representative, who does not have an existing Advance Directive, with written information and instruction regarding the right to make Advance Directives prior to the initiation of care or at any requested time. a. The resident may revise or revoke an Advance Directive at any time. c. The resident's instructions, the resident's receipt of written…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews the facility failed to thoroughly investigate, document findings, and follow up within 3 working days per facility grievance policy for 1 (#51) out of 1 (#51) resident reviewed for personal property. Findings: Review of facility's Filing Grievances/Complaints policy (undated) revealed in part: Policy statement: Our facility will assist residents or his/her responsible party in filing grievances or complaints when such requests are made. Policy Interpretation and Implementation: 1. Any resident, his or her responsible party may file a grievance or complaint concerning medical care, behavior of other residents, staff members, theft of property, etc. without the fear of threat of reprisal in any form. 3. Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident. 5. Upon receipt of written grievance and/or complaint, the social services director will investigate the allegations and submit a written…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure a criminal background check and sex offender registry check had been conducted prior to hire for 1 (S14 CNA[Certified Nursing Assistant]) of 5 (S12 CNA, S13 CNA, S14 CNA, S15 CNA, and S16 CNA) CNA personnel records reviewed. Findings: Review of undated policy on Abuse Prevention revealed: Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Procedure: A. Steps to prevent, detect and report: Screening: 1. The facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals or misappropriation of property. 3. The facility will pre-screen all potential new employees, volunteers, and residents for a history of abusive behavior. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a comprehensive, person-centered care plan had been developed and implemented for 4 (#6, #23, #30 and #54) of 29 sampled residents. The facility failed to ensure: 1. Resident #6 was monitored for anticoagulant use and AV (Arteriovenous) shunt was monitored. 2. Resident #23 was care planned for oxygen 3. Resident #30 was care planned for oxygen, nebulizer treatment minutes were documented and abdominal binder was in use 4. Resident #54 was care planned for having a PICC (peripherally inserted central catheter) line. Findings: Resident #6 Review of Resident #6's medical record revealed an admit date of 06/17/2024 with diagnoses which included in part, Chronic Kidney Disease, Stage 4 and Type 2 Diabetes. Review of Resident #6's medical record revealed the following physician's orders: 06/17/2024 Check AV shunt each shift; assess for bruit and thrill. 06/17/2024 Apixaban (anticoagulant) oral tablet 5 mg. (milligram); give 0.5 (half)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews the facility failed to ensure 1 (#53) of 2 (#6, #53) residents reviewed for nutrition received care as ordered by the physician and as stated in the facility policy. Resident #53 did not have weekly weights as ordered and the registered dietician's recommendations were not implemented. Findings: Review of facility's policy of weights (undated) revealed in part: Policy: All residents are weighed upon admission, readmission, and monthly thereafter to establish weight pattern and monitor for changes. Responsibility: Nursing assistants monitored by the licensed nurse. Procedure: 1. Each resident will be weighed by the 10th of the month. 2. Those residents with significant weight changes will be re-weighed by the 15th of the month. 3. The Dietician and/ or charge nurse or designee will determine which residents are to be weighed more frequently than monthly 4. Weights will be entered electronically. 5. When all the resident's weights on the unit have been obtained, the Charge Nurse is to review the weights for accuracy. 6. Upon completion of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, observations, and interviews the facility failed to provide appropriate treatment and services for 2 (Resident #30 and #257) of 3 (#24, #30 and #257) residents reviewed for tube feeding. The facility failed to ensure the tube feeding bottles were labeled properly. Findings: Review of facility's undated Tube Feeding policy revealed in part: Definition: A Nasogastric, Gastrostomy or Jejunostomy tube provides a method of administering nutrients directly into the stomach/GI (Gastrointestinal) tract and is indicated for those residents who cannot consume adequate nutrients safely via the oral cavity Procedure: 7. Label the feeding bag with the resident's name, formula ordered and date. Resident #30 Review of Resident #30's medical record revealed an admission date of 11/09/2022. Diagnoses included in part, Gastrostomy, Dysphagia and Brainstem Stroke Syndrome. Review of Resident #30's medical record revealed a Physician's order dated 07/04/2024, which read, Glucerna 1.5 at 60 ml (milliliters)/hr. (hour) x (times) 22 hours. Observation on 07/14/2024 at 9:40 a.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards of practice for 3 (#23, #30, #46) of 3 (#23, #30, #46) residents with an order for oxygen and/or respiratory treatments. The facility failed to ensure: (1) Oxygen tubing and humidification bottle were changed weekly for Resident #23 and Resident #30 and the oxygen tubing was stored properly for Resident #23. (2) Nebulizer mask was stored properly for Resident #46. Findings: (1) Review of the facility's undated Oxygen Therapy policy revealed in part: Equipment: 1. Source of oxygen delivery system (oxygen concentrator) 2. Humidifier, if needed 3. Oxygen connecting tube 4. Deliver service (cannula, mask,) Procedure: 1. Oxygen therapy is to be provided under the direction of a written physicians order. 8. Change tubing weekly. 9. Date tube when changed (weekly). Resident #23 Review of Resident #23's medical record revealed an admit date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure nursing and related services were provided to assure resident safety and maintenance of highest practicable physical, mental, and psychosocial well-being for 1 (#54) of 29 sampled residents. The facility failed to ensure Resident #54's PICC (peripherally inserted central catheter) line dressing changes had been conducted weekly. Findings: Review of policy for PICC Line or Midline Catheter Dressing Change revealed: Policy: A dressing change will be done to prevent external infection of the peripheral or central venous catheter. Responsible party: . Procedure: 1. Identify the resident and assess the resident's chart for any signs, symptoms of complications related to his/her vascular access device. 12. Document dressing change per facility protocol with initial and date. 15. Document treatment per facility protocol. 16. Assess the dressing change in the first 24 hours for accumulation of blood or moisture beneath the dressing. Change every 7 days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview the facility failed to ensure a licensed pharmacist had conducted a review of residents' drug regimen at least once a month for 5 (#1, #5, #17, #30 and #42) of 5 (#1, #5, #17, #30 and #42) residents reviewed for unnecessary medications. Findings: Review of undated policy for Consultant Pharmacist Services revealed in part: Policy: Consultant Pharmacist services are provided to residents, as required by federal guidelines. Responsibility: Executive Director, Consultant Pharmacist Procedure: . The pharmacy agrees to provide consultant pharmacist services in accordance with local, state, and federal laws, regulations, and guidelines. They will also abide by facility policies and procedures, and professional standards of practice. The facility will retain Medication Regimen Review reports and documentation of actions taken according to facility policy and/or state and federal guidelines. The consultant pharmacist will ensure that the following services are performed: 1.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure dietary services were provided in a sanitary environment for the 56 residents receiving a meal tray from the kitchen as reported by S5 Dietary Manager. The facility failed to ensure opened food items were labeled and dated; failed to ensure the sugar scoop was not stored in the sugar bin; failed to ensure a soda bottle was not stored in the ice machine; and failed to ensure the refrigerator and freezer were monitored at the proper temperature to prevent potential food borne illness. Findings: Observation on 07/14/2024 at 8:00 a.m. revealed 5 undated opened spice bottles, a scoop stored in the sugar container, and a staff member's soda bottle was stored inside the ice machine. Temperature monitoring for the walk-in refrigerator and freezer had not been completed since 07/11/2024. Monitoring for the three-compartment sink had not been completed since 07/11/2024. Temperature checks for food served had not been completed since breakfast on 07/12/2024. During an interview on 07/14/2024 at 8:30 a.m. S5 Dietary Manager…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to conduct (QAA) Quality Assessment and Assurance meeting was held at least quarterly. Findings: Review of facility's QAA binder with S1 Administrator failed to reveal any documentation of QAA meetings since last annual survey on 08/23/2023. During an interview on 07/16/2024 at 9:19 a.m S1 Administrator confirmed the facility's QAA binder did not contain any documentation of quarterly meetings since the last annual survey on 08/23/2023.

Based on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for 4 (#6, #17, #24, and #30) of 29 sampled residents. Findings: Review of the facility's Enhanced Barrier Precautions undated policy revealed in part: Definition: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of (Multidrug Resistant Organisms) MDROs in Nursing Homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. (for example) resident with wounds or indwelling medical devices). 2. EBP only require use of gown/gloves when performing high contact resident activities: a. dressing b. bathing/showering c. transfer (in room, shower/tub…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on personnel record reviews and interview, the facility failed to ensure provision of at least 12 hours of in-service training per year that included dementia management, resident abuse prevention, and care of the cognitively impaired for 5 (S12 CNA [Certified Nursing Assistant], S13 CNA, S14 CNA, S15 CNA, and S16 CNA) of 5 CNA personnel records reviewed. Findings: Review of S12 CNA's personnel record revealed a hire date of 05/08/2018. Further review of S12 CNA's personnel record failed to reveal evidence that S12 CNA had completed 12 hours of annual training. Review of S13 CNA's personnel record revealed a hire date of 09/21/2023. Further review of S13 CNA's personnel record failed to reveal evidence that S13 CNA had completed 12 hours of annual training. Review of S14 CNA's personnel record revealed a hire date of 06/25/2020. Further review of S14 CNA's personnel record failed to reveal evidence that S14 CNA had completed 12 hours of annual training. Review of S15 CNA's personnel record revealed a hire date of 06/25/2020. Further review of S15 CNA's personnel record failed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#44) of 2 (#1, #44) residents reviewed for accidents. The facility failed to ensure the post-fall assessment was accurately completed for fall risk. Findings: Review of undated Risk Evaluations policy revealed in part: Policy: Residents will have Risk Evaluations performed upon admission/readmission, quarterly, annually and with significant change in status. -Risk evaluations for falls, evaluation of pressure ulcer risk, evaluation of elopement risk, evaluation of smoking risk, evaluation of dehydration risk: 5. For residents who score at risk, develop a preventative care plan for that risk area. 6. Physical Therapy/Occupational Therapy/Dietary/Nursing are to review the appropriate Risk Evaluations on admission/readmission with a significant change, quarterly and annually to identify high risk residents. 7. The completed evaluation is to be stored in the Medical Record under…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, observations and interviews, the facility failed to ensure a resident who was unable to complete their ADLs (activities of daily living) received the necessary services to maintain proper grooming for 1 (#29) out of 1 (#29) residents reviewed for ADLs. The facility failed to ensure Resident #29 received nail care. Findings: Review of facility's Fingernails/Toenails Care (undated) revealed in part: Policy: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Responsibility: Nursing Assistant or Licensed Nurse Key Procedural Points: 5. Stop and report to the charge nurse any evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease. Review of Resident #29's medical diagnoses revealed: morbid (severe) obesity (07/13/2023), lack of coordination (07/26/2023). Review of Resident #29's July 2024 physician orders revealed an order dated 06/13/2024: clean, cut, and trim fingernails and toenails every week document any refusal; every Thursday. Observation on 07/15/2024 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.